HomeMy WebLinkAboutApp-Permit-ComplianceNo:. F' ' DC -1 -?3392— Ao6W 1AI Xg,( R4'1 / `" /� ( FEE b
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COMMONWEALTH OF MASSA64IJSETTS ck-1*15-
Board of Health, Fii�%�U , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair,/Upgrade ( ) Abandon( ) - ❑ Complete System �dividual Components
Location
Owner's Name
Map/Parcel# (Z,
Address CT
Lot#
Telephone#
Installer's Name0.
Designer's Name
Address /
Address
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
,.e�d>vywu yr • r�tca-crU � ��- „1„��.. ...•.- .- - - — - -- — - - - - r � - - The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of jompli a has been issued by the Board of Health.
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Signed I Date
r
Inspections
No. 60 4 339L COMMONWEALT14 OF MASSAC14USETTS
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CZIF .5I 535
Board of Health, l�-r/= —, MA.
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CERTIFICATE Of COMPLIANCE
Description of Work: 2 ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (VI Upgraded ( ), Abandoned
by: ,
at
has been installed in :accordance with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No..l% �`-��,(�dated Approved Design Flow - (gpd)
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Installer t . l 1 `.�f!{ �/t SIiLN l- ref / n/1!J
Designer: V kj Inspector: 2§ & CZ(A;�FXWJ !f Date:
The issuance of this permit shall not be construed as a guar ee that the system will function as designed.
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No. BOHDC 1-331-L Q 1 uoo" WrQ FEE "
AL/ COMMONWEALTH OF MASSACHUSETTS
Board (f Health, MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(110Upgrade( ) Abandon( ) an individual sewage disposal system
at 11 HEAZ(T AiJ5Ej2 L l , -�p as described in the application for
"'
Disposal System Construction Permit No., dated ' �; 1
Provided: Construction shall be completed within three years of the date of thisper it. All local onditions must be met.
Form 1255. Rev. 5/96 A.M. Sulkin Co: Charlestown, MA Date �~ '" ��->/Board of Health
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